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Topic Content

Healthcare-Associated Infections

Overview

Healthcare-associated infections (HAIs) are infections acquired while receiving medical care. HAIs occur in all health care settings including hospitals, long-term care, outpatient clinics, ambulatory surgery centers, and other outpatient services clinics. HAIs are often preventable. There are a multitude of HAIs, but there are primary types that state and national prevention efforts are focused on. Any HAI can quickly become life-threatening, and that is why it so important to focus on preventing them.

A. Clinical Description

Device related HAIs are linked to the insertion and use of a medical device. This could be a urinary catheter that is left in place and has a drainage bag that causes a catheter-associated urinary tract infection (CAUTI).  Another device commonly used is the central line. This is a vascular access device that is inserted into one of the great vessels and goes into or near the heart. These lines are used for infusions, blood draws, or even internal monitoring. The resulting infection is referred to as a central line-associated bloodstream infection (CLABSI).

Procedure related infections or surgical site infections (SSIs) are infections that develop after an invasive surgical procedure that required some type incision through the skin, (which does include laparoscopic approach) mucous membranes or cranial burr holes.

Multidrug resistant organism (MDRO) infections can develop in any part of the body including the bloodstream. These infections are particularly hard to treat as the organisms are resistant to many, or in some cases, all antibiotics. Carbapenem-resistant Enterobacteriaceae (CRE) is a particular group of antibiotic resistant organisms that is of great concern. These pathogens are not only resistant to most or all antibiotics, but can easily share their drug resistant genes with other pathogens.

Clostridium difficile infection (CDI) is an infection in the colon that causes severe diarrhea, and in some cases, other conditions of the colon. It is often associated with the use of antibiotics. It is most common in those that receive prolonged antibiotic treatment. It can be difficult to treat, and very easy to spread.

B. Sources of exposure

Most healthcare associated infections are transmitted via contaminated hands or surfaces and equipment. Transmission of microorganisms can occur during the insertion or maintenance of medical devices. Surgical procedures may also result in infection. Some infections can be transmitted through contact with respiratory droplets generated when a person coughs, sneezes or talks.

C. Population at Risk

Any person receiving healthcare is at potential risk of HAI. Those with medical devices such as urinary catheters, central lines, and ventilators or vulnerable populations such as the elderly, immunocompromised, and those with chronic conditions are at an even higher risk.

D. Diagnosis, Treatment, and Prognosis

Diagnosis is typically based on a combination of clinical signs and symptoms, recent medical history (examples: recent surgery, has or recently had an indwelling urinary catheter, has or recently had a central line) and ancillary testing such as cultures, other laboratory tests, and x-rays depending on the type of suspected infection.

Treatment will depend on multiple factors, the type of pathogen causing the infection, the site of the infection, and the patient. Antibiotics should be used judiciously.

Although great improvements in HAI prevention have been made, it is estimated that one in 25 hospitalized patients has at least one HAI. Furthermore, data suggests that about 75,000 to 99,000 deaths occur annually with HAIs.

The prognosis for those who contract an HAI is dependent upon the type of infection, the patient’s response to treatment, and the overall health of the patient.

E. Prevention of Exposure

Good hand hygiene is the best way to break the chain of infection. It is the single most important step in infection prevention. Patients and their families should practice good hand hygiene. They are also encouraged to make sure that all healthcare workers and visitors perform hand hygiene at a minimum upon entering and exiting the patient room. Here are some other measures healthcare facilities are taking to prevent HAIs:

  • Robust Infection Prevention and Control Programs help identify infection risks, educate staff on infection prevention and control, identify interventions to prevent infections and prevent the transmission of infections, communicate successes and need for improvement with the healthcare workers
  • Occupational health to ensure healthcare workers are healthy and protected from vaccine preventable diseases, therefore reducing the risk of patient exposure by staff
  • Reporting of infection data to a national database called the National Healthcare Safety Network can help identify areas that need improvement at the facility level. Those data are reviewed at the national level so progress and problem areas can be identified
  • Use of “prevention bundles” evidence-based set of interventions shown to decrease the chance of an HAI occurring 
  • Multi-disciplinary team or committee that is representative of many different areas or departments within the facility to get multiple perspectives on infection prevention risks and problem-solving
  • Improved inter-facility communication on potential infection transmission risks, laboratory results, antimicrobial treatments when transferring  or receiving a patient
  • Antibiotic stewardship to decrease unnecessary and excessive use of antibiotics that could contribute to antibiotic resistant organisms as well as cause C. difficile infections

A. Disease Reporting

A) CRE cases

CRE case reporting is required in Iowa. For the purposes of early identification and containment, all laboratories are required to forward CRE isolates from any body site (e.g., urine, blood, sputum, wound, etc.) and the results of antibiotic susceptibility testing and carbapenemase testing performed on the isolate to the State Hygienic Laboratory. CRE is defined as:  1)Klebsiella spp., 2)Enterobacter spp., 3)E.coli,  that is resistant to any one of the following carbapenem antibiotics: 1)imipenem, 2)meropenem, 3)doripenem, or 4)ertapenem, based on current Clinical and Laboratory Standards Institutes Standards (M100) or that demonstrates production of a carbapenemase

or

any Enterobacteriaceae that demonstrates production of a carbapenemase.

B) Outbreaks

All outbreaks should be immediately reported to the Iowa Department of Public Health by calling 800-362-2736.

C) Reportable disease occurring in the healthcare setting

Iowa Administrative Code (641) Chapter 1 requires reporting of certain Communicable and Infectious diseases to the Iowa Department of Public Health. Please see the Epi Manual Section “Reportable Disease Info.” When reported, public health may assist the facility with containment and outbreak investigation.

B. References

  1. National Healthcare Safety Network  https://www.cdc.gov/nhsn/index.html
  2. NHSN Patient Safety Component Manual January 2018 retrieved from:  https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf on 5/16/2018
  3. Healthcare Infection Control Practices Advisory Committee (HICPAC) Retrieved from: https://www.cdc.gov/hicpac/recommendations/index.html  on 5/15/2018
  4. Core Infection Prevention and Control Practices for safe Healthcare Delivery in All Settings_ Recommendations of the HICPAC(2017) Retrieved from: https://www.cdc.gov/hicpac/pdf/core-practices.pdf on 5/15/2018
  5. Public Reporting of Health Care–Associated Surveillance Data: Recommendations From the Healthcare Infection Control Practices Advisory Committee retrieved from: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/928512/ on 05/15/2018
  6. 16-ID-09 Committee: Infectious Disease Title: Interfacility Communication to Prevent and Control Healthcare-Associated Infections and Antimicrobial Resistant Pathogens across Healthcare Settings retrieved from: http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2016ps/16_ID_09.pdf on 5/15/2018